| NPI | 1609028943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 7245399-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA 2636) |
| Enumeration Date | 2008-10-17 |
| Last Update Date | 2009-03-29 |